Female Sexual Dysfunction: Common Problem But Uncommonly Discussed

Dr. Prathima Setty:
Hello. I am your host, Dr. Prathima Setty, and you are listening to ReachMD, the channel for medical professionals. Today we have with us Dr. Draion M. Burch, also known as Dr. Drai. He's a practicing physician and teaching faculty member at Magee-Womens Hospital of the University of Pittsburgh Medical Center. Dr. Drai is also the founder and chief medical advisor of DrDrai.com, where he discusses actionable ideas and real-world strategies to help women take control of their health.

Dr. Drai, welcome to the program.

Dr. Draion "Dr. Drai" Burch:
Thank you. It's great to be here, especially when I'm going to talk about my favorite subject, sex.

Dr. Prathima Setty:
Today we're going to talk about female sexual dysfunction. Dr. Drai, can you tell us your definition of female sexual dysfunction?

Dr. Draion "Dr. Drai" Burch:
So, this is just a huge topic. I see this every day of my life. About 20 to 60 percent of women have some sort of sexual dysfunction. You know, there's all these changes in estrogen levels that occur in various portions of their lives. I screen every patient for this. This is very important. I screen every patient because this is so common. So, first, let's go over the female sexual response.

So, there's four phases, to remind everyone. So the first phase is desire. So patients are generally really, really horny, and they kind of want to have sex now. So this can include sexual thoughts, their wishes, their images. So I always tell the patients, if you see a hot guy and you think about him making love to you, and if they say, "Yeah," I'm like, so that's desire. So you have desire for this. Another name for desire would be libido.

So the second phase would be excitement or arousal. So you're being sexually pleased, and there's changes that occur in your genital area. The vagina gets very engorged with blood. The heart rate can increase. The blood pressure can increase. Your breathing rate can go up, and then you get to the third phase, which is orgasm, reaching the big O. We all know about that, and then you have the resolution, which is the fourth phase, where the genital muscles relax and you feel complete. So that's the four phases of the female sexual response cycle.

So, female sexual dysfunction just means those three phases, low sexual desire, problems with getting aroused, or reaching an orgasm, and then additional issues with sexual pain. So that's your complete definition. So sexual pain, desire problems, arousal problems, as well as orgasm problems.

Dr. Prathima Setty:
So what would you say are some of the common causes of female sexual dysfunction?

Dr. Draion "Dr. Drai" Burch:
All over the place. The number one cause, I feel, is stress. Stress is the number one cause of female sexual dysfunction. You know, women are super moms, super career women. They are taking care of their kids. They are working these jobs. They're coming home, cooking dinner, taking care of their husbands, putting the kids to bed. Of course they're tired, right? Who wants to have sex after doing all that, right? No one, of course. So they're just tired.

So that's my number one issue I battle in the office. How to get the patient from being not fatigued, wanting to have sex. Their body's too tired, so of course they don't want to have sex, but medical conditions that you see this. So, high blood pressure, of course. Hyperlipidemia, diabetes, thyroid problems, even autoimmune issues like Lupus. So they can all affect arousal because they can affect the blood flow, nerve signals, and hormone levels, pelvic organ prolapse, and pelvic floor dysfunction that can occur during childbirth can also cause female sexual dysfunction. Endometriosis, as you know, can cause painful sex.

Urinary incontinence. So if you're urinating during orgasms or urinating during penetration, of course that can be alarming to a patient. Renal failure, fibroids can actually cause painful sex, and cancer. Especially if you had cancer and you had surgery, like pelvic surgery, or breast surgery, or radiation to those areas, and if you had chemotherapy that causes premature ovarian failure, of course you're going to have some type of female sexual dysfunction.

Depression is huge. So depression can lead to issues with desire, but depression being treated by SSRI like Prozac. Celexa's one. Paxil's one. Lexapro's another one. That can also cause even more issues, being on the SSRI. Anxiety. Patients that have MS, Parkinson's disease can have issues. Just menopause. Menopause can cause the lining of the vagina...that can cause painful sex, and one really good thing to know is breastfeeding can actually lower estrogen levels. So it can make the vagina more dry.

So the sex can be painful after they have a baby and they're breastfeeding. Their husbands always complain, "Oh, she doesn't want to have sex." Well, she's breastfeeding. Her vagina's not as thick as it would be. So it's going to be painful for her to have sex. So that's why she doesn't want to do it, and also breastfeeding can increase your prolactin, which can affect your desire and also can lower your testosterone.

You know, testosterone makes you horny. So that's important, and when you remove ovaries after a hysterectomy...ovaries is a source of testosterone, right? So, of course you can make the patient less horny when you remove that, and also, patients who have a history of sexual and physical abuse. I think those are important. Oh, I almost missed one. Relationship issues. So if you're fighting with your spouse, you're not going to have an orgasm.

Dr. Prathima Setty:
Those are all really good points and great possible etiologies for this very common problem.

Dr. Draion "Dr. Drai" Burch:
I just remembered. Birth control can cause you to have issues with, you know, sexual dysfunction. So that's one of the first things I do. Just remove all of the tings that can cause an issue.

Dr. Prathima Setty:
If you are just tuning in, you are listening to ReachMD. I am your host, Dr. Prathima Setty, and I am speaking with Dr. Draion Burch on female sexual dysfunction.

Dr. Draion "Dr. Drai" Burch:
Hey, it's great to be here, Dr. Setty.

Dr. Prathima Setty:
So, Dr. Drai, as far as the physical exam, are there certain signs and symptoms that you look for in a female sexual dysfunction patient?

Dr. Draion "Dr. Drai" Burch:
You always want to do a history and physical on the patient. So, you know, you want to assess any menopausal status. If they just had a baby, history of any pelvic injury, or cancer, or surgery, any vulva pain or pelvic pain, any itching or dryness they have down there, or discharge, abnormal bleeding. If they have any incontinence like urinary incontinence or fecal incontinence, that can be an issue, and you want to elicit a really good sexual history on the patient.

So the way I do that, I always ask them who they are attracted to, who they're having sex with. Men, women, or both, themselves, and then I usually get _____ (7:00) you're having sex with yourself as well. How are you having sex? You know, if you're having oral sex, anal sex, vaginal sex. It's very important to know, and then based off the female sexual response cycle, I start questioning, do they want to have sex? Do they have desire to have sex? During sex, are they aroused? Do they ever reach an orgasm, or do they have pain during sex?

So, really, the exam for a patient with sexual dysfunction is important for patients that have some sort of sexual pain, but in general, I like to do a full physical on the patient.

Dr. Prathima Setty:
And then, as far as treatments, can you talk about your non-medical therapies versus medical therapies? What do you use first, and when do you know to move on from there?

Dr. Draion "Dr. Drai" Burch:
The treatment is very, very complex for the FSD patient, female sexual dysfunction patient. Non-medical, I always refer to counseling, like sex therapy or couples therapy. If they have any issues with pain in the pelvis, I usually send them to get pelvic PT, physical therapy. Psychotherapy is huge for patients, especially if they're already on psych meds and you need to switch the medications around. Lifestyle change is the biggest one, and stress, and fatigue.

So you have to find a way for them to reduce stress, and I usually tell their husbands, hey, if you want to have sex with your wife, do some work around the house. Cook the dinner. Wash the dishes. Get the kids ready for bed. Wake them up. Get them ready for school. Walk them to the bus stop, and you're going to get some, trust me. Any way to reduce the stress, she's going to want to have more sex, and improving body image.

So a lot of overweight women just don't feel sexy. So I always tell them to exercise and lose some weight to get your sexy back. So you can also use lubricants and moisturizers in the vagina and devices. The only device, actually, that's FDA approved is this clitoral suction device, which is super weird to me. I usually prescribe vaginal dilators for patients that have something called vaginismus, and sex toys are huge.

So you want to have a sex toy. The best sex toy to get would be a vibrator or dildo. Make sure it's 100 percent silicone medical grade. That's the best and the least toxic for the patient, and direct masturbation is huge. For the medical, there's not many medications you can give for the patients. I have some off-label use. For post-menopausal patients, testosterone. They can benefit from a little bit of testosterone. Estrogen you can give if the post-menopausal patient has any vasomotor symptoms. Then you can give them estrogen.

There's a new drug on the market. It's called...oh, I forget. It starts with an O.

Dr. Prathima Setty:
Osphena? Is that the one you're talking about?

Dr. Draion "Dr. Drai" Burch:
Yes, that's it. Thank you, Dr. Setty. It's great to be on a call being interviewed by another OB/GYN. Yes. It is _____ (10:02) actually. I think it's 60 milligrams a day, and that's prescribed for painful sex. Have you prescribed that, Dr. Setty?

Dr. Prathima Setty:
A couple times, I have.

Dr. Draion "Dr. Drai" Burch:
How did it work?

Dr. Prathima Setty:
That's still yet to be determined. So, we'll see. I'm seeing a couple of them back.

Dr. Draion "Dr. Drai" Burch:
Exactly. I'm the same way. I'm not sure if it works or not, but there's FDA approval for a drug on the market, and a lot of patients, you know, if there's a pill to fix it, they want it, right?

Dr. Prathima Setty:
Absolutely.

Dr. Draion "Dr. Drai" Burch:
So, if they're taking an SSRI, the Celexa, and the Lexapro, and the Prozac...if they're taking any of that and the psychotherapist doesn't want to switch their medications because they're really controlled, you can add a little bit of Viagra, actually. So 50 milligrams or 100 milligrams one hour before sex. You can give them Viagra, and Wellbutrin, actually, can help women with this female sexual dysfunction with or without depression. So Wellbutrin's pretty good.

Dr. Prathima Setty:
I agree with you. It is quite complex, the treatment, and very individualized therapy.

Dr. Draion "Dr. Drai" Burch:
Correct.

Dr. Prathima Setty:
So, Dr. Drai, if the patient wants to find some more information on the Internet, where would you suggest them going for that type of information?

Dr. Draion "Dr. Drai" Burch:
There's this great website I use all the time. It's called AASECT. A-A-S-E-C-T dot org. It's the American Association of Sexuality Educators, Counselors, and Therapists. So this is where you're going to get a board-certified sex therapist and a counselor to help you with your problem with female sexual dysfunction.

Dr. Prathima Setty:
And is it online, or do they give a list and you have to go visit them? How does that work?

Dr. Draion "Dr. Drai" Burch:
Basically, you can put in your zip code, and they'll find all the sex therapists that are in your area, an then you would just call their office.

Dr. Prathima Setty:
Oh, that's a great resource. Dr. Drai, thank you so much for sharing your insights on female sexual dysfunction. It was a great review and will be very helpful to many healthcare professionals out there.

Dr. Draion "Dr. Drai" Burch:
Thank you for having me. Medical students and doctors, make sure you go to my website at DrDrai...that's D-R-A-I dot come and give me some feedback. Continue the conversation guys.

Dr. Prathima Setty:
Thanks, Dr. Drai.

Dr. Draion "Dr. Drai" Burch:
Thank you.

Dr. Prathima Setty:
You have been listening to ReachMD, the channel for medical professionals, and I'm your host, Dr. Prathima Setty. If you missed any part of this discussion, please visit ReachMD.com to download this podcast and others in the series. Thank you for listening.